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List of Job Duties for an Insurance Processor

Insurance processors usually bear titles of claims examiners or claims processors. Generally responsible for adjudicating claims presented against an insurance policy, they must verify the claimant's policy and benefit eligibility before processing the claim. Whether the processor has a job in an insurance company that handles automobile claims, workers' comp claims, home insurance claims or other insurance policies, the job duties are usually the same.

Claims Review

The first person to review the claims submitted against an insurance policy, the claims processor also enters or authorizes the claim entry into the company's computer system. She assigns a number or identifier to the claim along with establishing anticipated costs for it. If the claim form is incomplete, the processor contacts the claimant to ask them to finish the form or provide additional information. Once the claim is in the computer system, the processor establishes internal diary dates to ensure milestone and follow-up dates are set.

Investigation and Fact Gathering

After the initial review, the claims examiner begins an investigation into the facts presented by the claim. With vehicle accident claims, for example, this entails requesting the police report for the accident and the name and contact information of any witnesses. The processor then contacts any witnesses to conduct interviews to ascertain or verify the facts in the case. The processor also completes an over-the-phone interview with the claimant.

Third-Party Investigations

In cases that suggest potential fraud, a claims processor may contact an outside private investigator to conduct an additional investigation. The private investigator works closely with the claims processor to support or refute the testimony of the claimant. For example, the private investigator might videotape employees who claim back injuries performing activities their injury suggests they cannot perform, such as unloading groceries or household supplies from their vehicle. If the investigator proves fraud, the claims examiner works with the local district attorney to prosecute insurance fraud.

Claim Acceptance or Rejection

After reviewing the testimony presented by witnesses and the claimant, and the investigator's report if conducted, the processor verifies she has all facts in the case. She then makes a decision to accept or reject the claim. In workers' comp cases for example, individual state law sets the dates by which the claims examiner must contact the claimant, accept or reject the claim or make disability payments.

Payments and Settlements

Claims examiners and processors are also responsible for setting financial reserves on claims based on the claim's future costs, authorizing payments to claimants, for medical treatment if warranted, automotive repair shops or other repair companies once a claim is accepted. The claims processor examines the details in the case to establish and offer a settlement amount based on the value determined by the individual case. The claims processor might also work with legal counsel to negotiate a settlement agreement.



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